Provider Demographics
NPI:1093891095
Name:LARSEN SERVICE DRUG, INC.
Entity Type:Organization
Organization Name:LARSEN SERVICE DRUG, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:701-444-2410
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763-0460
Mailing Address - Country:US
Mailing Address - Phone:701-627-2410
Mailing Address - Fax:701-627-2400
Practice Address - Street 1:334 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763-0460
Practice Address - Country:US
Practice Address - Phone:701-627-2410
Practice Address - Fax:701-627-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21402Medicaid
ND1206540002Medicare NSC